Living into the Tensions of “Primary Care Behavioral Health”

Blake Edwards, MSMFT, LMFT

Editor’s note: In October, executives from migrant health centers across the U.S. joined in Asheville, North Carolina, for the annual Migrant Health Best Practices Forum. The theme was “innovation.” Topics presented included “Using Data and Technology to Transform the Care of Farmworkers Living with Diabetes,” “Addressing Burnout and Compassion Fatigue in Healthcare Workers: An Experimental Approach to Mindfulness,” “Patient Experience and Journey Mapping Strategies,” “Employee Wellness,” and more.

Blake Edwards, who served as the lead behavioral health champion for Washington’s Pediatric Transforming Clinical Practices Initiative (P-TCPi), presented, “Primary Care Behavioral Health: Living into the Tensions.” We asked Blake to share a snapshot of what he presented:

Three lessons about how best to implement primary care behavioral health

First, integrated behavioral health providers must by-and-large remain consultants and generalists if the integrated model is to serve its primarily-needed purposes as a PCP-extender and primary care team member. To the extent that a provider serves a dual-role as an integrated behavioral health consultant (BHC) and co-located behavioral health therapist, they are less available to serve those purposes.

Secondly, BHCs must be treated as members of the primary care team. If the BHC does not maintain physical proximity to the other primary care team members in the course of daily flow, they will not be treated as a member of the primary care team. If the BHC does not participate in team huddles and (at least some regular) medical provider meetings, and if they are not regularly accessible in the team’s pod, they will not be treated as a member of the primary care team.

Third, BHCs must be sufficiently available to PCPs. If there is not sufficient BHC capacity to well serve the PCP team and patient population, there will be much angst—PCPs will be left as the de facto mental health treatment provider, primary care flow will be clunkier than otherwise, and patients will not be best served. The “golden rule” for primary care behavioral health is 1:4 (BHC: PCPs); 1:3 in pediatrics.

Part of maximizing utilization requires a paradigm shift from PCPs acting as the “quarterback”—a commonly used football analogy that does not align with principles established for Patient-Centered Medical Homes (PCMH). According to core principles jointly established by six professional societies of family medicine, the PCMH model is marked by a team-based approach rather than a physician-centric approach (Baird et al., 2014). Therefore, we need a new analogy. I view the PCP as a pitcher and the BHC as a catcher. Given a host of nuanced factors, the catcher may – not uncommonly – call the pitch (curveball, knuckleball, fastball – to the inside, to the outside). The pitcher may veto the call, but even then, there’s good collaboration. Most importantly, pitches from pitcher to catcher are highly routine.

With much left to study and debate, one thing is clear: innovation requires living into the tensions.

Blake Edwards is the behavioral health director at Columbia Valley Community Health and serves as a Governing Board Member for the North Central Accountable Community of Health.


Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., Epperly. T., Green, L., Henley, D., Kessler, R., Korsen, N., McDaniel, S., Miller, B., Pugno, P. Roberts, R., Schirmer, J, Seymour, D., & deGruy, F. (2014). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183-185.